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Organization
IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES
Active
Organization
IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ED AXFORD II (PROGRAM MANAGER)
(208) 234-7900
Entity
Organization
Contact information
Practice address
223 N STATE ST, PRESTON, ID 83263-1140
(208) 852-0634
(208) 852-2136
Mailing address
421 MEMORIAL DR, POCATELLO, ID 83201-4008
(208) 234-7900
(208) 236-6328
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010019235
BLUE SHIELD
ID
05
—
8073684
—
ID
01
—
HW108
BLUE CROSS OF IDAHO
ID
Enumeration date
03/08/2007
Last updated
08/22/2020
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